Medical Errors

Medical errors should obviously be avoided as much as possible; patient safety and lives are at stake. However, the world and members of the health professions within the world are not and will never be perfect. Therefore, a certain number of errors are inevitable. If you haven't been involved in one yet, you will. Your reaction and what you do afterwards may be critical in either improving the situation or making it worse.

An excellent reference book on how medical errors occur has recently (2004) been written by Drs. Robert Wachter and Kaveh Shojania, entitled Internal Bleeding, which should be required reading for all health care professionals. As a result of this book and recent publicity about the frequency of errors in health care, a great refocusing of effort on patient safely has occurred nationwide. Hospitals and clinics across the country have evaluated and improved their procedures for patient care with the primary goal of reducing the safety "holes" through which patients sometimes fall resulting in medical errors.

There has also been a refocusing of the medical community regarding who is to blame when errors have occurred. Previously, the final individual involved in the cascade of events leading to an error was the person who was blamed. More recently there has been a greater attempt to evaluate the whole system of events leading to the problem. When this is done, it is usually found that there are several loopholes in the safety net leading up to the medical error.

For example if a particular medication has a very similar name to another medication, is stocked on the same shelf, and if its label on the bottle looks similar, there are a number of events that could occur leading up to an adverse event or medical error, beginning with the way it is stocked. The physician who writes the order or prescription may not write the name of the medication plainly. The pharmacist may pull the wrong medication off the shelf and dispenses it to the nurse on the floor, who perhaps notices that the medicine looks a little different than the last time she gave that same medication, but she's in a hurry and doesn't question it. She gives the medication, and the patient, who also notices the medication doesn't look the same but doesn't question it, has a serious reaction. It is discovered later that the patient received the wrong medication. Who's fault is it? How could this have been prevented?

If you look at the whole cascade of events, there are several problems starting with drugs with similar names, having similar labels on bottles stocked on the same shelf. The stocking and labeling of these medications could have been done differently. The physician could have printed the name of the medication more clearly. The pharmacist didn't check the name on the label carefully because the label looks so similar to the other medication, and neither the nurse nor the patient questioned the different appearance of the drug when s/he received it. There are a lot of places where this error could have been prevented. Medical facilities are constantly evaluating things like this and taking whatever steps necessary to close these loopholes.

Despite this renewed effort, adverse events still occur as much as we don't want them to. If you are involved in the process of events leading to a medical error, how should you handle this?

First, you want to be sure the patient is treated quickly for whatever the adverse event is that has occurred. If no adverse effect occurred, that's great, but there are still several things that need to be done.

Risk management should be notified and a complete evaluation of why the error occurred should be undertaken. Once the problems are identified, steps should be taken to ensure that the same error doesn't happen to someone else; because if you don't change something, it will happen again.

Try to document as well as you can, unemotionally, in the chart what actually happened without placing blame on any individual.

Sooner or later, someone is going to have to tell the patient or his/her family what happened. This usually falls to the physician or nurse who is primarily responsible for the patient's care. The Patient Advocate for the hospital or clinic may also want to be involved in the discussion.

The best thing to do is be honest and explain what the error was and what led up to it, and assure them that a full investigation will take place so that it won't ever happen again. Do not pin the blame on any particular individual, but rather emphasize the combination of factors that led to the problem. Most patients understand that none of us are perfect and that errors do happen and will accept the explanation. Some will want to have the doctor or nurse removed from their case, with which you should comply. A few will want to get the records and obtain a legal opinion which of course is their right.

When discussing a medical error with the patient or family, express concern about the error, never be too cavalier about it, and make sure to take steps to ensure that it doesn't happen again. If you do this, the patient will know that you are distressed that this happened and that you are concerned about their safety and their welfare. Depending on how severe the adverse effect is, the patient or family may not be happy about it, but their anger or frustration may be tempered by your reaction to it. The patient advocate and the risk management team may also be helpful.

If you have previously built a good relationship with the patient and family, this will go a long way in helping to diffuse the situation. If you have not, the frustration may not be reconcilable. So you can see how important your initial contacts with the patient and family are in building a trusting relationship. You never know when you might need that relationship to help you and them get through a messy situation.